Scoliosis & Pelvis - P

 The pelvis is the lost bone in scoliosis, especially since many spine radiographs were performed without the femoral heads. As an introduction, the most recent data in the literature will be summarize.

 The pelvis is the lost bone in scoliosis, especially since many spine radiographs were performed without the femoral heads. As an introduction, the most recent data in the literature will be summarize.

 The lumbar—pelvic—femoral complex is an entity relevant to posture, with interconnections and compensations between the spine and lower limbs. The anatomy of this pelvic vertebra has changed with the evolution of species, notably with the transition to bipedalism, with the consequent appearance of lumbar lordosis. Trunk imbalance can to some extent be compensated for by the pelvis and lower limbs.

 For Dubousset, the pelvis may be seen as a single vertebra, between the spine and the lower limbs.

 The fundamental constitutional parameter for each patient is the lumbopelvic incidence. If this incidence for Lenke 5 lumbar scoliosis is compared with a control group of the same age, there is a higher pelvic incidence: 46,8 versus 41,3. But there is no difference for Lenke 1 thoracic scoliosis. This study proves the role of the pelvis for lumbar scoliosis.

 Similarly, for de novo adult degenerative scoliosis, which mainly involves the lumbar region, the pelvic incidence is higher than in the same age control group: 51,1 versus 47,7. The mechanism is probably the same as for adolescent lumbar scoliosis. The mechanism is probably the same as for adolescent lumbar scoliosis.

 This recent publication on the sitting position of adolescent scoliosis, confirms a greater retroversion in the sitting position.

 This awareness of the sitting position is the first step in restoring isostatic balance in the sagittal plane prior to 3D correction by coupled movements.

 Even if the global three-dimensional displacement during walking is not modified in adolescent scoliosis, the muscular activity is different. The duration of activation of the erector spinae in the sagittal plane and of the quadratus lumborum in the frontal plane is prolonged. This is probably also a compensation for the increased lumbopelvic incidence.

 The lumbopelvic parameters in the sagittal plane are one of the basis of the Lyon Method and have already been discussed in other presentations. The objective of this work is the classification in the frontal plane. For simplicity, we will distinguish 5 parameters: Lumbo-sacral scoliosis Lumbo-pelvic scoliosis Pelvic elevator or exposed hinge Leg Length discrepancy Coronal balance

 The lumbosacral junction is fundamental in the study of scoliosis and yet often ignored. It conditions the progression risk of scoliosis in adulthood.

 The first concept is that of the tilt of L4 in the frontal plane, which may be the cause of lumbar scoliosis by ligament asymmetry. This asymmetry was named Asymmetrical Structural Anomaly of the Lombo-Iliac Junction by Jean du Peloux and has been an integral part of the Lyon Method for over 50 years.

 Since the Rhesus monkey, the muscles of the quadrupedia connecting the transverse processes of L4 and L5 to the iliac wing have been transformed into ligaments. The transverse process of L4 is in fact stabilized by its insertion on the iliac wing and by an insertion on the transverse process of L5. There are frequent asymmetries that can be appreciated by a major tilt of L4.

 The tilt of L4 is measured from the bi-crest line. The consequence for physiotherapy is the opening of the iliolumbar angle, based more on the soft tissues than on the bony spine. The opening of the ilio-lumbar angle is obtained by an extension of the lower limb on the side of the lumbar convexity here on the left.

 The consequences are also important at the level of bracing. In case of ASALIJ, the priority is the horizontalization of L4, which is obtained not by corrective lumbar bending, but by a shift or frontal translation of the lumbar spine to the line of gravity during the second scan in corrected lumbar position.. This is the convex iliac plateau of the ARTbrace or the short brace GTB.

 This concept is illustrated by a clinical case. the Taiwan clinical case number 6 concerns a 14-years-old girl with lumbar scoliosis of 39° Cobb angulation and thoraco-lumbar kyphosis in the sagittal plane.

 In the frontal plane, there is clinically significant asymmetry in the waist fold. The tilt of L4 is major corresponding to the ASALIJ. This ASALIJ is often associated with other anomalies: L5-S1 is exposed, with the bicrested line intersecting L5.

 The C7plumbline is unbalanced towards convexity. There is an opening towards the concavity of the L3-L4 disc, without concave elevation of the iliac crest with however rotation of the pelvis towards the concavity. It is therefore a case of an excluded pelvis with 2 out of 3 characteristic signs.

 It could be specified that some genetic mutations are more related to the severity of curvature with significant Cobb angles, but their presence is not a prognostic factor.

 Even if the spine is globally balanced in the sagittal plane, lumbar lordosis and thoracic kyphosis are significantly reduced.

 Each of the elements of the classification induces its own therapeutic approach. For lumbosacral scoliosis, it is the opening of the ilio-lumbar angle corresponding to a convex ilio-costal lengthening.

 In the frontal plane, the ilio-lumbar angle can be opened laterally on the side of the concavity and initially the physiotherapist uses the lever arm of the lower limb in the axis of the trunk to lower the convex iliac crest, seeking to include the pelvis in the lumbar scoliosis. Manually all the convex structures are stretched. Then the stretch can be completed by derotation of the pelvis in a horizontal plane. The lower limb is positioned 90 ° to the trunk towards the convexity while the trunk rotates 90 ° towards the concavity so that the chest rests on the examination table.

 In degenerative scoliosis, the situation is sometimes more difficult because the initial imbalance towards convexity can be compensated by a thoracic curvature. In such cases, correction of the lumbar scoliosis must be combined with opening the ilio-lumbar angle.

 This patient will serve as a common thread throughout this presentation to illustrate the approach methodology. The tilt of L4 is often less obvious when there is an oblique bicrest line, because the obliquity artificially decreases the tilt of L4. In this case, the imbalance of the C7plumbline towards convexity is an additional argument for ASALIJ.

 The second concept concerns the lumbo-pelvic scoliosis with pelvic tilting. The included pelvis extends the lumbar scoliosis and is part of it, partially compensating for the scoliotic deformity, whereas the excluded pelvis, which is anatomically fixed, will increase the lumbosacral stresses.

 This concept was developed by a French team of surgeons who found that the King and Lenke classifications did not take the pelvis into account.

 Indeed, for the same major double scoliosis, the surgical indication will be different if the pelvis is included as on the left or excluded as on the right.

 A Canadian team estimates the rate of included pelvis at 21%, regardless of conservative or surgical treatment.

 The 3 characteristics of an included pelvis on a frontal X-ray are: 1. Parallelism of the L3-L4 disc, 2. Raised concave iliac crest, 3. Pelvic rotation toward the concavity (wider concave iliac projection on X-ray ),

 It is possible to quantify this pelvic rotation. The graphic scheme from the Evaluation method for axial pelvic rotation according to the width of the hip bone was applicated. It was published in Czech journal in 2015.

 The 3 characteristics of an excluded pelvis on a frontal X-ray are: L3-L4 intervertebral disc with concave opening, Even iliac crest or slightly higher 3. No or slightly rotation in this case towards convexity

 The concept of included or excluded pelvis is also independent of etiology, although included pelvis is more common in neurological scoliosis.

 Inclusion of the pelvis corresponds to scoliosis involving more vertebrae, the pelvis being considered a pelvic vertebra. As the lever arm is larger, correction is easier. The underarm brace must necessarily stabilize the pelvis.

 At least 2 out of 3 elements are needed to define the included or excluded pelvis. We have parallel discs and concave pelvic rotation but In this case, the iliac crests remain quite balanced.

 The opening of the L4-L5 disc on the concavity is probably a prognostic element for adult scoliosis The included pelvis with no leg length discrepancy does not justify compensation. Included pelvis + ASASIL + LLD + coronal imbalance are sometimes associated.

 Each of the elements of the classification induces its own therapeutic approach. For lumbopelvic scoliosis in case of included pelvis, the pelvis will be stabilized with stretching of the concave lower limb, (the opposite of ASALIJ). In case of excluded pelvis, the Reduction limited to the lumbar spine, with a possible short bracing.

 After the ASALIJ, our common thread patient has the 3 characteristics of an included pelvis with parallel L3-L4 disc, elevation of the concave iliac crest and rotation of the pelvis towards the concavity. Corrective physiotherapy should therefore combine opening of the convex ilio-lumbar angle and concave ilio-costal lengthening.

 The ilio-lumbar angle can also be opened in a half-seated position on the concave ischium. The physiotherapist asks the patient to flex the convex lower limb to lower the convex iliac crest. In this position, it is easy to manually carry out a corrective shift from the convexity to the concavity which moves the transverse insertion of L4 toward the gravity line and stretches the concave ligaments. One can use this technique of lengthening the ilio-costal concavity in case of association ASALIJ and included pelvis.

 The third concept concerns the position of L4 in relation to the iliac crest. When the bi-crest line intersects L5, the lumbosacral hinge is said to be exposed.

 Our bipedalism has induced the transformation of the muscles of the quadruped into very strong ligaments at L5-S1. The most characteristic is the ilio-transverse ligament of L4 which has existed since the Rhesus monkey in the evolution of bipedalism.

 Normally the bicrest line usually intersects the vertebral body of L4

 The prognostic factors for instability are superimposed on those for the progression of curvature. Increased intervertebral disk degeneration is difficult to evaluate on X-ray, but an exposed lumbosacral hinge with intercrest line through L5 favors disc degeneration and one should be very careful and if possible prevent degeneration in these cases.

  In this patient, the inter-crest line intersects L4. Lumbosacral stability is optimal.

 In this patient, the inter-crest line intersects L5 and we note the progression of scoliosis between 17 and 27 years of age.

 The pelvic elevator operates when the lumbosacral hinge is exposed. Degeneration of the L4-L5 and L5-S1 discs must be prevented. The patient will then be advised: 1. To avoid extreme amplitudes (limited Range of Motion), 2. to avoid lumbar flexion and rotation together, 3. to avoid axial shocks.

 Our common thread patient besides ASALIJ, the included pelvis also has an exposed hinge with bi-crest line intersecting the superior vertebral plate of L5. In addition to exercises, prevention of low back disc degeneration should be emphasized.

 The fourth concept concerns the leg length discrepancy and functional scoliosis.

 In the setting of leg length discrepancy (LLD) functional scoliosis occurs when the lumbar spine compensates for pelvic obliquity to maintain coronal balance. More than 2 cm LLD may result in degenerative changes of the lumbar spine, altered gait mechanics and low back pain.

 Limb length discrepancy was present in 87%of patients with a degenerative scoliosis. In 79% of patients with single lumbar curve, the apex of scoliosis was opposite the high iliac crest side like included pelvis. There is no side prevalence for double curve.

 In the case of a single curve, the scoliosis extends from the pelvis to the scapular girdle. In case of a double curve, the thoracic curve limits the imbalance of the scapular girdle.

 The Functional Scoliosis or scoliotic attitude is a compensation of an uneven pelvis. The rotation can be the opposite of the flexion like paradoxal scoliosis.

 The pelvis is unbalanced at the level of the iliac crests posteriorly and the anterior superior iliac spines anteriorly. Leg Length discrepancy is measured at the level of the femoral heads.

 A first measurement of the hump is made without compensation. The hump is on the longer side, it is most often a functional scoliosis. With compensation, the hump decreases. In these cases, we compensate with a heel pad equal to 2/3 of the inequality in length.

 The indication depends on the severity of the LLD. 1. less than 1 cm: no compensation. 2. Between 1cm and 2 cm: compensation only if the rib hump decreases with compensation and to rebalance the occipital axis. 3. Between 2 cm and 4 cm: always compensation and discussion of epiphysiodesis during growth. 4. More than 4 cm Epiphysiodesis or discussion of limb lengthening.

 When this leg length discrepancy exceeds 2 cm, compensation is possible if it does not accentuate the rib hump and if it goes in the direction of a rebalancing of the occipital axis. In this case, it is probably a functional scoliosis because the lumbar rotation is minimal.

 In this case, the leg length discrepancy is also associated with a functional scoliosis. Lumbar rotation is minimal. At Risser 0, epiphysiodesis of the right knee appears to be the best solution.

 In this extreme case of leg length discrepancy, right epiphysiodesis is probably insufficient and may be associated with a lengthening of the left lower limb.

 Our common thread patient also has LLD. Our common thread patient also has a LLD. 2 Adams tests, one with compensation, the other without compensation will be performed. The compensation is legitimate if the rib hump decreases with compensation. If a brace is performed, compensation can also be used if the occipital axis imbalance persists.

 The fifth concept concerns frontal imbalance. The imbalance is most often towards the concavity with often inclusion of the pelvis. It can also occur on the convex side especially with ASALIJ. The correction technique will be different.

 Frontal imbalance is also a warning sign of instability, it can occur either on the concavity side or on the convex side of the main curvature. In the case of concave imbalance, the correction is made at the level of the scoliosis, as in the adolescent. In case of a convex imbalance, the correction is made at the pelvis level with the opening of the ilio-lumbar angle characteristic of the Lyon method.

 We see on this montage realized by the authors of the article the good realignment in case of concave malalignment, and on the contrary the accentuation of the imbalance in case of convex malalignment, when one tries to correct the scoliosis.

 For unbalanced scoliosis, the correction technique will be different. For imbalances towards convexity, geometric detorsion between the scapular girdle and the pelvic girdle is preferred. For concave imbalances, mechanical detorsion at the curve level is preferred.

 This patient at the end of her statural growth presents a main left thoraco-lumbar curvature with imbalance towards convexity. The pelvis is excluded with L3-L4 opening towards the concavity, without elevation of the concave iliac crest and without rotation. The bicrest line intersects L4, The asymmetry of the waist fold is major. The indication is that of a classic underarm brace like ARTbrace with regional moulding in 3 steps. The lumbar shift will be performed from left to right and the thoracic correction with the right hand on the head. To compensate the left imbalance, the left axillary cutout will be raised 1.5 cm compared to the right side.

 The common thread patient also has an imbalance towards convexity. The fifth concept was purposely placed last, as the previous corrections in most cases will have corrected the occipital axis imbalance.

 The physiotherapy program will be developed after identifying the 5 concepts. For our common thread patient, we will combine: 1. Opening ilio-lumbar angle, 2. ilio-costal concave lengthening, 3. intervertebral disc prevention, 4. shoe lift Adams testing, 5. Geometrical detorsion to rebalance.

 Even if some combinations of parameters are more frequent than others, it will be necessary to carry out an analytical study for each patient to elaborate the physiotherapy program.

 In daily practice, the 5 concepts can be combined and must be analyzed separately. The main clinical cases presented during the interactive sessions were grouped.

 Another case of imbalance towards the concavity, but parallelism of the L3-L4 disc, elevation of the concave iliac crest and rotation of the pelvis towards the concavity. It is indeed an included pelvis. L5-S1 is exposed in favor of a progression risk in adulthood. The lumbar rib hump is minimal without lumbar rotation. In physiotherapy, the emphasis will be on correction of the thoracic curve with, in case of brace, a slight iliac plateau on the left.

 This 34-year-old patient presented with a large left thoracolumbar curve. The tilt of L4 reflects an ASALIJ and we have the 3 characteristic signs of an included pelvis: parallelism L3-L4, elevation of the concave iliac crest and rotation of the pelvis toward the concavity. L5-S1 is exposed in favor of a progression risk in adulthood. Overall, the occipital axis is balanced. In physiotherapy, we will work on the global correction of the thoraco-lumbar curvature.

 The indication is that of an adult ARTbrace thoracolumbar type. If the curvature is rigid, the moulding will be done in one step with the right hand on the head, asking the patient to shift from the left to the right and providing a support point on the right trochanter.

 This boy also has an included pelvis with the 3 characteristic signs; parallelism of the L3-L4 disc, elevation of the concave iliac crest and rotation of the pelvis towards the concavity. L5-S1 is exposed in favor of a progression risk in adulthood. Lower extremity imbalance is minimal, with right thoracic rib hump predominating without lumbar rotation. There is a convex imbalance.

 Compensation to the left should allow for rebalancing of the occipital axis and decrease the functional lumbar scoliosis. However, the thoracic curve may increase on the Adams test with compensation. In physiotherapy, the correction will be focused on the right thoracic level with extension of the left upper limb and the right lower limb,

 This 32-year-old patient has a well-balanced right thoracolumbar curvature with no ASALIJ and pelvis included. The 3 signs are characteristic: parallelism of the L3-L4 disc, elevation of the concave iliac crest and strong rotation of the pelvis towards the concavity. The bicrest line is tangent to the lower plate of L4. There is no significant LLD and coronal imbalance, but an imbalance of the scapular girdle.

 Physiotherapy will be carried out with extension of the right upper limb and the left lower limb by asking the patient to shift from the right to the left. The elevation of the left shoulder goes in the direction of the correction of the thoraco-lumbar curve, but risks accentuating the initial imbalance. Treatment with adult ARTbrace for 6 months will promote geometric and mechanical detorsion. The shoulders will be balanced in the brace.

 This patient has a characteristic ASALIJ and included pelvis with parallelism of the L3-L4 disc, elevation of the concave iliac crest and rotation of the pelvis toward the concavity. The bicrest line intersects the left low corner of L4. The imbalance is towards the convexity. There is a high lumbar rib hump, but little asymmetry of the waist fold. The right shoulder is slightly elevated.

 In physiotherapy, in addition to aligned geometric detorsion, the indication is lumbar shift, left hand on the head to avoid accentuation of the thoracic curvature. 30° Cobb angulation justifies the ARTbrace 18 months.

 This 32-year-old patient was generally well balanced and had an included pelvis with a good prognosis. There is parallel L3-L4 disc, elevation of the right concave iliac crest and rotation of the pelvis towards the right concavity. The bicrest line intersects the lower plate of L4. There is a Leg Length Discrepancy with minimal Lumbar rotation, the rib hump is predominantly right thoracic.

 Physiotherapy will focus on the right thoracic curvature with extension of the left upper limb and the right lower limb. In principle, no compensation by shoe lift to avoid accentuating the thoracic curve. The prognosis is favorable.

 In conclusion, the integration of the pelvic vertebra in the correction of scoliosis has always been one of the basis of the Lyon Method. The logical analysis in the frontal plane in 5 points is performed for each patient and will define the physiotherapy program and the correction in brace.